With the passage of the Patient Protection and Affordable Care Act (PPACA) in 2010, the subsequent midterm elections, then the states' collective lawsuit leading to the Supreme Court decision, followed by a national election, Americans have been on a PPACA rollercoaster. But the ups and downs of the ride have perhaps been more a barometer of uncertainty about the act's survival rather than a reflection of public opinion. In contrast to the peaks and valleys of PPACA politics, public opinion has remained remarkably steady.

Since the bill was passed in March 2010, overall opinion about the PPACA has varied only slightly, with about 40 percent of Americans reporting disapproval, 37 percent approval, and 23 percent having no opinion of the health care law (Kaiser Family Foundation 2013: 3). Of course, this question about overall support has always been somewhat misleading, since most of the dissatisfaction comes from the individual mandate. When the public is asked about other aspects of the PPACA, such as the requirement to cover those with preexisting conditions and allowing children up to age twenty-six to stay on their parents' policies, support is very high (85 percent and 68 percent approval, respectively [New York Times2012]).

This disjuncture in approval ratings between specific provisions and overall support raises questions about the sources of public opinion: is public support for the PPACA driven by self-interested concerns or assessments about what is best for the American collective? If self-interest is the motivator, how do individuals assess how the bill will affect their care? Do they consider past experiences or rely on external information about the future to determine the appropriateness of health reform provisions? Similarly, if they base their support on collective determinations, what are the sources of information used to arrive at what is best for the collective?

In this issue of JHPPL, we are fortunate to have two articles that explore exactly these questions. Stuart Soroka, Antonia Maioni, and Pierre Martin explore Canadians' support for their health care system, and Lilliard Richardson and David Konisky examine Americans' support for health care reform during the 2009 congressional debate. Drawing from literature on economic voting, both articles consider the interaction of personal versus collective assessments with retrospective versus prospective evaluations. This approach helps us make sense of the often divergent findings of positive personal experiences amid decreasing confidence in the system's ability to meet future needs. Both studies reveal the importance of prospective evaluations, whether based on personal or collective concerns, and therefore the importance of drivers external to personal experience in shaping public opinion. Although neither study uncovers what those external drivers are that shape prospective assessments, they point the way for future research. It is crucial to the workings of democracy to understand whether prospective assessments emerge from reasoned collective deliberation, “objective” information sources, or as Benjamin Page (1994: 26) has written, “from some top-down fashion by elite manipulation, media biases, or government propaganda.” Given numerous findings showing the link between public opinion and policy outcomes, the influence of the latter on shaping the former is particularly troubling.

The importance of understanding public opinion, and concerns about how it might be manipulated and shaped, becomes paramount when one considers policy preferences around fundamental life-and-death questions, such as organ transplantation policy. All developed countries face a fundamental problem with organ transplantation: it is a life-saving procedure for those facing end-stage organ failure, yet demand outstrips supply. This problem has produced numerous proposals to increase the supply of organs, but none — aside from a purely voluntary system — come without serious ethical concerns.

The most popular proposal of late is a reciprocity system whereby registered donors are offered some degree of priority in the allocation of organs ahead of those who are not registered. While there are plenty of articles on the ethics of reciprocity systems, relatively few studies have analyzed public opinion on the topic. Jacquelyn Burkell, Jennifer Chandler, and Sam Shemie help fill this gap by examining whether there is a difference in support for reciprocity systems based on whether the individual is a decided donor. This is quite interesting in light of the other two articles discussed above, because they look directly at the influence of self-interest on preferences. In particular, does the priority incentive influence support among decided donors? In considering the influence of donor intention, they study Canadian public opinion on two questions: Do people think a reciprocity system is fair? Do they believe a reciprocity system will increase donor registration (i.e., efficacy)?

While decided donors are more likely to believe a reciprocity system will be more efficacious, they are no more likely than undecided donors to think the system is fair. In other words, while they believe others will be motivated by self-interest, they do not use their own self-interest to assess whether the system is fair for the collective. Since positive assessments of efficacy lead some to support a policy of reciprocity (regardless of their view on fairness), it raises important questions about the generation of data on efficacy and its potential impact. Again, drawing on the studies above, prospective information on efficacy could be highly influential and points to the importance of getting such information “right.” On the other hand, it is unclear whether such information should be used in light of citizen questions about the collective fairness of reciprocity.

The last research article in this issue examines media framing of a public health issue in the global South. Despite the World Health Organization's declaration of alcohol abuse as a major contributing factor to death, disease, and injury, media discourse around alcohol control is only occasionally focused on its public health implications. Mary Lawhon and Clare Herrick document newspaper coverage between 2007 and 2011 of two South African alcohol control policies and show how media framing shifts according to views of the perceived legitimacy of alcohol retailing based on who is doing the selling and alcohol consumption based on who is doing the drinking. They discuss the disjuncture between framing alcohol use for pleasure among the middle and upper classes as economically necessary and morally legitimate, on the one hand, and alcohol use in poor areas as automatically rendered an illegitimate activity, on the other. Importantly, they explore the link between media framing that is contingent on political ideologies, moral beliefs, and medical knowledge and the formation of alcohol control policy. And all the while public opinion is lurking in the background. Can the public form an opinion, which is separate from these moral depictions of deservingness and steeped in a history of spatial and racial divisions of perceived legitimate and illegitimate behavior?

Report on Health Reform Implementation

I am pleased to announce that we have another new section in the JHPPL pages, which will include essays on the implementation of health care reform either at the federal level or across the fifty states. We kick-started the section in the last issue with an essay that explained our new JHPPL-led scholar-practitioner engaged network (please see that issue's editorial note for more details). From this network we will solicit essays from practitioners and scholars to report on implementation efforts and to critique the process (perhaps even highlighting what should be done but is not). All essays will be available open access to the public through the generous support of the Blue Shield Foundation of California and the Robert Wood Johnson Foundation.

In the first essay of the section, “Why States Expand Medicaid: Party, Resources, and History,” Lawrence Jacobs and Timothy Callaghan provide an important contribution to understanding the implementation of the Medicaid expansion now and in the future by proposing a “process” measure as opposed to a “generosity” measure. The process approach asks how far along states are in deciding to adopt new Medicaid provisions. Using this measure, they find that factors other than partisanship are important. State affluence, past policy trajectories, and administrative capacity all influence a state's propensity to implement.

Behind the Jargon

Finally, for our biannual Behind the Jargon essay, Martin Powell and Robin Miller consider the use of the term privatization under England's National Health Service (NHS). They argue that when the term is used in popular discourse it lacks definitional and analytic precision and is often conflated with “marketization.” In response to this ambiguity, they examine privatization through four dimensions: state, market, voluntary, and informal. They differentiate these dimensions according to finance and the provision of services to shed light on which NHS policies might be viewed as moving toward some level of privatization. By presenting a “scientific” typology of privatization, one can see more clearly how the term is used strategically in policy discourse. Moreover, this typology may be useful for cross-national comparative research.